Student version of discussion cases: Dysuria

• Define and differentiate causes of dysuria.
• Identify patients with likely uncomplicated UTI and best method(s) of treatment
• Learn laboratory tests that are helpful in differentiating causes of dysuria.
• Recognize subtypes of patients risk for complicated UTI’s and/or other causes of dysuria.

Bent S, Nallamothu BK, et al, Does this woman have an acute uncomplicated urinary tract infection? JAMA, May 22/29, 2002;287(20):2701-10. May be found at: http://jama.ama-assn.org/cgi/content/full/287/20/2701 

Bergus GR, Dysuria (Chapter 27). In: Essentials of Family Medicine, 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams and Wilkins, 2012, 327-336..

Case 1:

A 50 year old woman presents with 1 week of dysuria and denies vaginal or other urinary symptoms.

Question 1:  What is your differential diagnosis?

Question 2:  What further evaluation would help you establish a diagnosis?

Question 3:  Assuming that her UA indicated infection, what is your first-line treatment? 

Case 2:

21-year-old female generally healthy presents to office with 3d h/o urinary frequency and  burning on urination.  She has increased her water intake without benefit.  She is a college student with a new male sexual partner, and uses OCP’s.  She denies fever, chills, back pain, or  vaginal discharge.  PMHx Neg. On physical exam, her vitals are normal and she has suprapubic tenderness, but no CVAT. UA: 1.030 / 1+LE / -blood / -nitrate / -glucose / -pro, 2-5 WBC / hpf 

Question 1:  Does this female have uncomplicated UTI?   

Question 2:  Does use of lab (UA / micro) costing the patient $37.00 help your differential diagnosis?
                 
Question 3:  What are her risk factors?

Question 4:      What are likely organisms causing a UTI?

Question 5:      What should you use to treat her?

Case 3:

34-year-old female presents with 10 d h/o dysuria, mild urinary frequency. She note chills and aches, but has not taken her temperature.  She is on Depo Provera so her LMP is unknown. She is uncertain about vaginal discharge.  PMH: UTI 8 years ago.  UA 1.015/ - LE/ - blood/ - nitrate.  On physical exam, vitals are normal. Pelvic: mild erythema of external genitalia, no vaginal discharge or cervicitis, no CVAT or cervical motion tenderness.

Question 1:            Does this female have UTI?  

Question 2:            Does she exhibit any red flags for complicated UTI?

Question 3:            What (if any) treatment should be given? 

Question 4:            Should further testing be done?   

Case 4:

78-year-old male nursing home resident has 1 week of worsening incontinence, complaints of pain in penis, and inability to sleep.  His nurse reports more confusion, especially at night.  His past medical history is significant for HTN, high cholesterol, new depression, and a hip fracture 2 months ago.  UA 1.025 / 2 + LE / 1 + blood / 1 + glucose / + nitrate. Microscopy shows 20-50 WBC / rare bacteria / 2-5 RBC/ 10-20 Epithelial cells/ hpf. You will not be able to perform a physical until the end of the day.

Question 1:      Do you need to ask further history or order other lab tests before beginning treatment? If so what?

Question 2:      What concerns you regarding UTI in this patient?

Question 3:      How would you treat a UTI in this case?